1. Hospitals were no longer places to go and die.
2. New technologies were introduced.
3. Aseptic and antiseptic techniques were introduced. Hygiene improved tremendously.
4.  Surgical procedures advanced
5.  Nursing grew

•    Early in the nineteenth century, most Americans saw the hospital as a place that protected the rest of the community from the sick.  (Quarantine)
•  In the 1800s and before, people saw the hospital as a place where people went to die.  
•   Hospitals were places for the poor with little to no family ties could go for care; they were charity hospitals. 
• But after the Civil War, hospitals grew at a rapid pace and the charitable mission of the hospital began to change

·      Hospitals evolved from 1870 to 1910 as science and technology moved ahead.  They evolved into local workshops for physicians treating all classes of patients. 

·      By 1873, there were an estimated 178 hospitals in the U.S.; by 1909, there were more than 4300 hospitals in the U.S.

• Few hospitals are built
• Started as Proprietary schools for profit and not rigorous curriculum or lab
• In 1910the Flexner Report is released and schools become more focused on teaching and research centers and this report caused structural changes in the hospital.
• Abraham Flexner conducts a survey of 155 medical schools
• John Hopkins was used as a model because it was the first school to offer a 4 year degree.
• Flexner made recommendations that changed the way schools were run.

1. Reducing the number of medical schools from 155 to 31 university schools committed to medical research and academic excellence.
2. Medical school admission requirements should include at least two   years of college with preparation in biology, chemistry, and physics.
3. Medical schools should obtain strong financial support for modern labs and hospital facilities.
4. Medical schools should emphasize the scientific method and time in the laboratory and clinic.
5. Original research should be a core activity of medical schools.
6. Medical schools should have a large staff of full time professors in clinical and scientific departments

• There was a modest expansion in the number of hospitals. 
• The Hospital Survey and Construction Act of 1946 (Hill-Burton Act)
• The increased breadth and intensity of hospital care was also fueled by:
• The rapid growth of insurance to pay for care.
• The rapid growth of Medicare and Medicaid to pay for care.

1. created federal funding sources to build new hospitals, expand and renovate facilities, increase bed capacity, and add emerging technology. 

2. During the Act’s existence, about 15% of hospital construction was funded through Hill-Burton funds. 

3. The Act was killed in 1974 as a result of having too many hospital beds.

·      The second period of rapid growth starts slowing down.

·      Changes in hospital payment systems changed hospital behavior and structure.

·       The number of hospitals has decreased as hospitals merged with each other.

·      Competition became fierce as hospitals began advertising and developed new services and programs. 

·       A host of new services were added that were not traditional inpatient care.

- Also, managed care organizations are more strongly depending on cost containment mechanisms

Two of the same types of facilities join together, usually for efficiency.

Competition became fierce as hospitals began advertising and developed new services and programs

Joining of different firms, usually for service expansion.

9  Hospitals could now offer different services such as rehabilitation services, home health care, outpatient

    services, and nursing homes.

1. Prior approvals for drugs

2. Second opinions from physicians

3. Contracting with hospitals that charge lower prices for their services

Prices for services that are set by the hospital: 

1. Room and board

2. Services provided (ex. meals)

3. Medicines

 This is a system to classify hospital cases into one of almost 750 different groups Based on:

1.  Clinical diagnosis
2. Whether it’s a surgical procedure
3. Age
4. Sex
5. Presence of complications
6. Other clinical information

·      examples include:

•           Pneumonia, Heart failure, C-section, Hip/knee replacement

1. Location of the hospital (rural or urban)
2. Teaching status (Teaching gets more than non-teaching)
3. Amount of care provided to low-income patients

1. Rehabilitation facilities         
2. Psychiatric facilities
3. Children’s hospitals 
4. Cancer hospitals
5. Long-term care facilities/hospitals
6. Rehabilitation and psychiatric units in the hospitals   
7. Home-health agencies
8. Hospices
9. Hospital-outpatient facilities
10. Skilled nursing facilities

Balanced Budget Act (BBA) of 1997

established prospective payment for: 

1. Long-term care facilities/hospitals
2. Rehabilitation and psychiatric units in the hospitals   
3. Home health agencies         
4. Hospices                
5. Hospital outpatient facilities 
6. Skilled nursing facilities       

• Separate prospective care is used for reimbursing care at each of these facilities.

This act was also designed to reduce Medicare reimbursements to hospitals, physicians, home health agencies and skilled nursing facilities by $115 billion from 1998-2002. 

•   In response to backlash
• The Balanced Budget Refinement Act in 1999 restored $8.4 billion to Medicare reimbursements.
• The Benefits and Improvement Protection Act (BIPA) in 2000 restored another $11.5 billion in Medicare reimbursements.

• With PPS, payments are determined in advance and are fixed.
•   With PPS, the unit of payment changed from per day to per admission.
• With PPS, payment rates are independent of each hospital’s own cost experience.

1. Decreases in the number of inpatient admissions and length of stay.
2. Increases in post-hospital use of services (nursing home care, home health care etc)
3. Unbundling of services
4. DRG code Creep
5. Dumping

· Hospitals are classified as short-term if the average length of stay is less than 30 days.

· Most hospitals are short-term.

· Short-term hospitals are also called acute-care hospitals.

Average lengths of stay for long term facilities are 30 days or more

·       General hospitals provide a variety of services, including general medical and surgical services, obstetric services, etc.

·       Specialty hospitals concentrate on one disease like psychiatric diseases, cancer, or tuberculosis, or one  segment of the population such as children or veterans.

·        Most hospitals are general hospitals.

·       Public hospitals are owned agencies of the federal, state, and local governments.

·       Federal hospitals are usually designed for special beneficiaries: American Indians, veterans, military personnel,

·       Many states operate psychiatric treatment facilities.  These would be state-run, specialty hospitals.

·       Local governments like counties can also own and run hospitals.

·       State and local hospitals are noted for their efforts in handling uncompensated cases. 

·       Private hospitals can be either non-profit or investor-owned.

·       For-profit hospitals have to distribute some of their profits to investors while non-profits have no investors that they must pay dividends to; there is nobody to distribute the “profits” to.

·       Community hospitals include all nonfederal, short-term general and some specialty hospitals that are available to the public.

·       Non-community hospitals are not open to the general public. 

They include federal hospitals for military personnel and Veterans Affairs hospitals

·      Teaching hospitals may be expressly associated with a medical school or may have an affiliation with a medical school.

·      Teaching hospitals serve as sites for physician residencies.

·      Teaching hospitals perform a lot of uncompensated care and a large percentage of tertiary or highly complex services.

·       Hospitals are part of a multi-hospital system when they are either leased under contract by another hospital or are legally incorporated by or under the direction of a board that determines the control of two or more hospitals. 

• Outpatient visits increased
• decrease in length of stay has to do with the prospective payment system
• Hospital closures were largely a response to a massive transformation in the delivery of patient care. More outpatient care, decrease in length of stay, and hospital mergers.
• Most hospitals are non-government, not for profit.

1. Board of directors --> in “for profit” hospital
2. Board of trustees --> in a “non profit” hospital

1. To establish the mission and goals of the hospital.
2. They are going to develop hospital policies.

The board of directors/board of trustees has primary authority and control of the hospital and delegates duties to two other groups

1. Hospital Administration or Management Team
2.   Medical Stall or Professional Staff Organization

·       The hospital administration or management team implements the policies of the board. 

·       The hospital administration or management team includes a hospital administrator or CEO

·       Although it varies from hospital to hospital, there might be Vice Presidents for: 

           **Finance

           **Planning and Marketing

 **Nursing

 **Professional Services – looks over pharmacy, physical therapy, respiratory therapy. They look over all profressional services.

 **Support Services – laundry, security, powerplant (non professional)

 **Human Resource Management

Has its own organizational chart and bylaws of operation. 

Divided by specialty.  Some specialties may include:

1.             Internal medicine
2.             Surgery
3.             Pediatrics
4.             Obstetrics/gynecology
5.             Psychiatry
6.             Pathology
7.             Radiology
8.             Anesthesiology

There are three ways a physician can work for a hospital:

• Physician can be a private practitioner who is not an employee of the hospital. This is the most common type of doctors at a hospital. They are just allowed to use the hospital for admitting and treating their patients. They have an office elsewhere.
• Physician can be a full time employee of a hospital. They probably have a salary and the hospital will provide them an office. Less common. 
• Some physicians maintain their own private practices outside of the hospital, but receive a part-time salary from the hospital for administrative work. Least common. They may be the chief of a service, but they have their own private practice.

This is a non-governmental body that has its purpose to set standards for hospitals and healthcare facilities and subsequently accredit hospitals and other healthcare facilities based upon those standards

Evaluatie in an on-site survey that occurs unannounced in a time frame between every 18-39 months. Make sure you are always prepared since you never know when they are coming

1. Ambulatory Care Centers
2.  Behavioral Health Care Facilities
3. Critical Access Hospitals
4. Home Health Care Organizations
5.  Laboratory Services
6. Long Term Care Facilities
7. Office Based Surgery Facilities

covers patient, client or resident-focused functions that relate directly to the provision of care, treatment and services: 

1.  Ethics, rights and responsibilities
2. Provision of care, treatment and services
3. Medication Management
4. Surveillance, prevention and control of infection

contains organization functions that are vital to the organization’s ability to provide high-quality care, treatment, and services:

1.       Improving organization performance
2.       Leadership (they evaluate the leaders)
3.       Management of the environment of care
4.       Management of Human Resources
5.       Management of Information (monitor HIPAA)
6.       Medical staff and nursing services

1. First, the Centers for Medicare and Medicaid Services (CMS) allows Joint Commission Accreditation to be an alternative to a specific Medicare/Medicaid approval.  The way in which this works is: In order for a health care organization to participate in and receive payment from the Medicare or Medicaid programs, it must be certified as such by the CMS.  In some cases, CMS can take Joint Commission accreditation for this approval instead.

2.  Accreditation status also influences managed care contract decisions as many insurance carriers consider this accreditation in making reimbursement decisions.  Many insurance plans limit their payments to accredited hospitals. 

3. It may also fulfill state licensure requirements.  Many states rely in whole or in part on Joint Commission accreditation in granting certification and/or licensure.

1. Oversees personnel and human resources issues (hiring, firing, performance appraisal)
2. Manages the hospital’s drug budget
3. Set quality standards for the department
4. Evaluate policies and procedures
5. Implementing new programs
6. Ensures compliance with Joint Commission, department of public health, and board of pharmacy

1. Staff Pharmacists- in-pharmacy duties like checking medications.

2. Clinical Pharmacists - on the floor doing counseling

3. Charge Pharmacists - floor manager of sorts

Staff and Other Support Personnel

1. Technicians

2. Interns

3. Stock Technicians

4. Administrative assistants

5. Purchasers

1. Floor-stock distribution – older method
2.   Unit-dose distribution – the current accepted method

Floor stock distribution involves supplying the nursing staff with a pre determined number of dosage forms, which are stored in a separate drug room in each nursing unit.  Nurses then dispense the medications based on physician’s orders.

 WHAT IS THE PROBLEM WITH THIS TYPE OF DRUG DISTRIBUTION SYSTEM?

• Pharmacists can’t review the doctor’s order for the patient.        
• Pharmacists can’t review patient’s profile. No idea if there are drug interactions going on or anything.

·    As orders come to pharmacy throughout the day for patients, the pharmacist enter the orders into the computer, a Medication Administration Record (MAR) for the patient and all of their medications is created

·  That day’s worth of medication is filled by the pharmacist and is taken up to the floor either by delivery, or a tube system or some other method. 

·    Through the night, the technicians will print the MARs for the patients and fill patient cassettes of all the medication they will need for the next day, and the pharmacist will check it and place in the patient’s drug cassette whereby itis delivered first thing in the morning (or some other time during the day). 

 Just like the name of the distribution method suggests, the drugs are packaged in unit doses

1. Drug Therapy Monitoring
2. In-Service Education
3. Drug Information Services
4. Specialized Clinical Pharmacy Services
5. Adverse Drug Reaction Monitoring
6. Medication Utilization Evaluations
7. Formulary Development
8. Therapeutic Substitution
9. Purchasing and Inventory

Multidisciplinary Care

Many different professionals, somewhat independent of each other, working for the good of the patient. (not really working together though) 

Many different professionals working together for the good of the patient, communicating effectively among themselves and with the patient (and caregivers) [team based approach] 

Podiatrists - DPM

Psychologists

1. Threat of New Entrants
2. Rivalry Among Existing Firms
3. Threat of Substituted Products
4. Bargaining Power of Buyers
5. Relative Power of Stakeholders
6. Bargaining Power of Suppliers

**Barriers to entry:

1. Customer Consolidation
2. Managed Care and third party payers

• This is the effect of Health insurance increasing utilization.

• This is important in the Factors Contributing the Growth Rate of National Health Expenditures

  during 1960s- 1980 and 1980-1993
•  •When we remove out of pocket costs consideration from decision making then more people are going to utilize health care. During this time period more people had coverage and had the ability to utilize healthcare. So more and more people were insulated from costs, and the government involvement in 1960 was a big contributor to this. 
• •The medical technology was more expensive, the more things we could diagnose and treat that were never thought of increased, the drug discovery increased.
  •The 1970s were characterized by high levels of inflation explains some of the high % of growth of health costs.
  •When there are more people, we spend more on health care. We had a huge population growth during this period.
  •People, relative to 30s and 40s, are living longer than they had before which gave a large aged population

• (increases in this type of care cause drop in growth rate)
• Important in the 1994-1998 growth rate of national health expenditures

– more and more people begin to move to managed care programs. (Managed care was associated with drug utilization and working with providers to limit price increases. They do this by restrict people’s choices. Employers wanted to lower the costs of the health insurance they were having to pay. US auto-manufacturers also had a hard time because they were having to pay the growing healthcare expenditures. Managed care began to help do this by moving people into these programs that reduced price and utilization of healthcare) 

1999-2003 Growth Factor of National Health Expenditures 

2004 – 2007 Growth Factors in Health Expenditures 

Some states after expanding Medicaid, then contracted Medicaid which put more people on uninsured list

2008 Growth Factors in National Health Expenditures

2009-2019 Growth Factors of National Health Expenditures

There is growth because:

• •Baby boomers will start getting Medicare coverage
  •Baby boomers (a large cohort of people) will have more sicknesses and ailments that will make the period interesting.
  Technological innovations will also contribute to cost growth

Definition: the amount of all the goods and services that are produced within a defined geographic area (a country). As more of our dollars go to healthcare we have less money to go to other goods and services.

Lower periods of growth, then there is a huge portion of the GDP spent on healthcare. The large growth in 2009 represents the largest 1 year increase in GDP reflecting severity of recession and lack of economic growth (numerator grows, denominator doesn’t). If you are spending the majority of your income on healthcare then you don’t have the money to contribute to other things

safety concerns – There were several drugs that had large media coverage and showed that maybe there is not a pill for every illness and that there are good medications but some do more harm than good

changes in the therapeutic mix of drugs

it means the reduction of preventable errors and reduced variability in evidence-based best practices

The U.S. mental health service system is complex and connects many sectors (public–private, specialty–general health, health–social welfare, housing, criminal justice, and education). As a result, care may become organizationally fragmented, creating barriers to access. The system is also financed from many funding streams, adding to the complexity, given sometimes competing incentives between funding sources. 

A long time advocate for treatment of the mentally ill. She would approach legislators with goal to create asylums. She wanted them to be a safe haven where they could be together and thus protect the public. Funding was given, but they were large and understaffed so counseling and treatment was minimal or poor, and the people admitted were rarely allowed to leave. (“Mental Health Prisons”) Dorthea Dix also tried to capture the amount of people in the US via a census to figure out how many people suffered from a mental illness. 

• Joint commission on Mental Illness and Health, Action for Mental Health. (This act allowed for the discovery of drugs and helped the pharmaceutical industry realize there was a market for mental health so they created drugs to sell.

*Post WWII, mental disorders became more treatable with medications, which fostered more optimism toward treatment and prevention*

• Funded construction and staffing of community mental health centers (CMHC) (no longer has to be State Hospitals (whitfield) or large facilities) 

National Comorbidity Survey (1990-1992) – Another large study (3^rd since 1955) that adhered to the World Health Organization and so we could compare internationally. We have more mental illness than other industrialized nations.

NCS – Replication (2005) – used DSM 4 criteria to enumerate and gather data, consistent with WHO criteria, and it acts as a mental health census so we could figure out where to allocate our resources. 

The four sectors of the Mental Health System

1. Specialty Mental Health Sector
2. The general medical/ primary care sector
3. The Human Services Sector
4. The Voluntary Support Services Sector

• Specialty mental health services include services provided by specialized mental health professionals (psychologists, psychiatric nurses, psychiatrists, and psychiatric social workers) and the specialized offices, facilities, and agencies in which they work.
• Specialty services were designed expressly for provision of mental health services

• The general medical/primary care sector consists of health care professionals (family physicians, nurse practitioners, internists, pediatricians, etc) and the settings (offices , clinics, and hospitals) in which they work.
• These settings were designed for the full range of health care services, including, but not specialized for, the delivery of mental health services

•  
  • The human services sector consists of social welfare, criminal justice, educational, religious, and charitable services. 

•  
  • The voluntary support network refers to self-help groups and organizations.
  • These are groups devoted to education, communication, and support, all of which extend beyond formal treatment. 

• Refers both to services directly operated by government agencies (e.g. state and county mental hospitals) and
• to services financed with government resources (e.g. Medicaid, Medicare)   

• refers both to services directly operated by private agencies
• Financed through private agencies (employer-based-insurance) 

• History of insurance and mental health care
  • Believed to result in high costs
• Catastrophic care guaranteed by public mental health system
• Traditional forces at play in insurance (moral hazard and adverse selection) may have been exaggerated. Impact of managed care 

• Cost controls
  • Lowered fees, reduction in utilization (fewer hospital stays and less time in mental health services) and shifting to ambulatory setting.
  • Managed behavioral health care organizations (MBHOs). 

1. Mental Health Parity Act
2. Mental Health Parity and Addiction Equity Act

3. Stigma
4. Prevention
5. Entry into treatment 

signed into law in 1996, requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan.

                                                               i.      For example, in 1975, MS’s annual cap on mental health expenditures was $1,000.

is a federal law that provides participants who already have benefits under mental health coverall parity with benefits limitations under their medical/surgical coverage.  

• “Some feel embarrassed, helpless, frightened, powerless, uncomfortable, or self-protective when working with patients with mental disorders.”
  • Pharmacists frequently interact with a wide variety of patients with mental, cognitive, and emotional disorders.
• Pharmacists must acquire the knowledge and interpersonal skills, including observation, to interact effectively with these patients.
• Familiarity with the MMSE
• Familiarity with local services and state services for mental illness and addictive disorders. 

A model for quality, compassionate care at the end of life. Involves a team-oriented approach to expert medical care, pain management, emotional, and spiritual support expressly tailored to patient’s needs and wishes

1. Dying is a natural part of the life cycle
2. Belief that we each have the right to die pain-free and with dignity. 
3. Practitioners seek not to hasten nor postpone death but instead provide comfort and supportive care while the patient's illness runs its course. 
4. Emphasis is not on death and dying but on living each day until the death comes
5. Not only the patient receives care but the family does as well. 

Role of Hospice Programs

o   Provide comprehensive palliative care to terminally ill patients and supportive services to their families and significant others, 24 hours a day, seven days a week, in both home and facility based settings.  

o   With physician oversight, the patient and family receive physical, social, spiritual, and emotional care during the later stages of the patient’s illness, during the dying process, and during the family’s bereavement period. Hospice doesn’t stop for family after patient is buried. 

  The active total care of patients whose disease is not responsive to curative treatment.

The management of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is the quality of life. 

The team works together to provide the patient/family with support and guidance as they confront common challenges associated with dying. 

Team Members include: 

1. Medical Director
2. Attending/ Primary Physician 
3. Nursing Care
4. Home Health Aides
5. Social Services
6. Chaplains or other counselors
7. Volunteers
8. Bereavement Care 
9. Pharmacists 

Duties:

1. Refer and recruit patient admissions
2. Educate on hospice and EOL care to medical community
3. Coordinates care with attending physicians
4. Leads interdisciplinary team
5. Admissions, certifications, re-certifications,
6. EOL pain and deaths 

This is the patient’s designated physician for medical care

Duties:

1. Certifies patient’s prognosis
2. Continues ongoing medical care/consultation for patient’s disease state and symptoms after hospice admission
3. Signs death certificate 

Clinical Coordinators, Admission nurses, Case Managers (RN), LPN ,Triage Team

Duties:

1. Provide medical care to a patient two-three times/week
2. Assess and monitor patient’s condition
3. Consult with MD on patient’s plan of care
4. Coordinate medication use/education
5. Coordinate other necessary supportive care (DME, medical supplies, etc.

Duties: Assist patients with transfers, bathing, eating, etc. Provide support to family/caregivers to address their needs 

Duties: Counseling and supportive services Assist in preparation of end of life (i.e. legal issues, vacations, funeral arrangements, etc.) 

Duties: Life review/counseling Prayers and spiritual services for any religion 

Duties Trained community persons to assist families in their time of need Provide support in any possible way Grocery shopping, respite hours, transportation, etc. 

Duties: Support services to friends and family after the patient’s death for up to one year.

• Bereavement support is provided by various disciplines depending on the hospice (i.e. social work, chaplains, psychologist, etc.) 

1. Assessing the appropriateness of medication orders and ensuring the timely provision of effective medications for symptom control.
2. Counseling and education the hospice team about medication therapy
3. Ensuring that patients and caregivers understand and follow the directions provided with medications.
4. Providing efficient mechanisms for extemporaneous compounding of nonstandard dosage forms.
5. Addressing financial concerns (we can get meds generic and can work with social workers and manufacturers)
6. Ensuring safe and legal disposal of all medications after death.
7. Establishing and maintaining effective communication with regulatory and licensing agencies

·         introduced hospice to the US in the late 1960s.

o   The first hospice was founded in 1967 by Dame Cicely Saunders, a British physician. Saint Christopher Hospice of London 

Reserving such services for terminally ill Medicare beneficiaries with life expectancies < 6 months. How many hospice patients? 963,000 are expected to die while in hospice, about 38% of deaths

• Designed to meet the unique needs of those who have a terminal illness, providing them and their loved ones with special support and services not otherwise covered by Medicare.
• Under MHB, beneficiaries elect to receive non-curative treatment and services for their terminal illness by waiving the standard Medicare benefits for treatment of a terminal illness (meaning they would not pay for chemotherapy or something like that once they agree to Hospice. You can still have Medicare just don’t file for that terminal illness so all the other things a patient is on can still be paid for (high BP, etc))
• However, the beneficiary may continue to access standard Medicare benefits for treatment of conditions unrelated to terminal illnesses

•                    Physician

•                    Nursing Care

•                    Home health aide

•                    Chaplain

•                    Social Work

•                    Bereavement

•                    Medical equipment and supplies

•                    Medications

•                    Volunteer

•                    • PT, OT, ST, and/or dietary counseling 

• Services for conditions unrelated to the terminal illness.
• Services for the terminal diagnosis that are not called for in the hospice care plan or arranged by hospice.
• Room and board in a facility.
• in-patient care and respite care can be covered if deemed necessary by hospice team
•  Hospice care from another provider (other than one associated with your hospice team).

•                    Drugs intended to cure disease.

•                    Care in an emergency room, inpatient facility care, or ambulance transportation, unless it’s either arranged by your hospice medical team or is unrelated to your terminal illness 

1.      Certified by the patient’s primary physician and hospice medical director that the patient is terminally ill and has a life expectancy of six months or less.

2.      Sign a statement choosing hospice care using the MHB, rather than curative treatment and standard Medicare covered benefits for their terminal illness.

3.      Enroll in a medicare approved hospice program. 

1. Admission certification
2. Re-Certification
   1. Two 90-day periods followed by unlimited 60-day periods. (Its open ended if you don’t die within your 6 months)
   2. The patient must demonstrate disease progression or decline from terminal illness to be re-certified (continue eligibility for MHB). (If they have no health decline or no tumor growth or whatever, then they may lose hospice if they will live for years. If there is some sort of progression of decline then they usually stay)

                                                               i.      The patient MAY be discharged if they do not continue to meet eligibility requirements. 

• Other patients are referred to hospice only in the final days of their lives 
• Some dying patients never get referred to hospice
• Only 38% of patients die with hospice care. 
• Length of stay ~3 weeks nationally, more than a third of patients spend less than seven days enrolled in hospice
• Difficulties with prognosis
• Inability to accurately predict prognosis Limited public awareness 
• Cultural differences and barriers contribute to an inequitable distribution of hospice services

health care provided to non-institutionalized patients.  “Outpatient” care, usually on an appointment basis.

Inpatient – hospital, overnight, surgery, more

1.    Rapid growth of managed care

2.    Greater emphasis on shortened hospital stays/ more outpatient care.

3.    Drugs sparing hospital visits because they are OTC (statins, anti-hyperlipidemics, antibiotics)

4.    Technology has increased

Increases in ambulatory care = decreases in health care costs 

1. Access
2. Insurance status (people with no health insurance won't go to health clinics because they can't afford it so they go to expensive emergency rooms) 

•     Differences in access for different minority populations, income brackets, and women.
•     Disparities lead to differences in deaths from heart disease, cancer, stroke and diabetes (the 4 top killers), as well as other illnesses.
•    “ HRSA (Health Resources and Services Administration – responsible for improving access) envisions optimal health for all, supported by a health care system that assures access to comprehensive, culturally competent, quality care.”

(Remember that cultural competence improves care because of language barriers, being aware of different disease risks of different population.) 

Primary care = medical care oriented toward the routine needs of patients (diagnosis, treatment of common illnesses, etc.)

Secondary care = routine hospitalization and specialized outpatient care

Tertiary care = complex services provided in inpatient hospital facilities

• ·         "ambulatory care” not equal to primary care
• ·         Primary care is one type of ambulatory care

o   Patients principle source of general outpatient medical care

o   Generally a longitudinal relationship

• ·         “Accessible” (in theory), located in the community settings.
• ·         “First stop” for most personal health care needs
• ·         Integrates/coordinates other needed services (via referrals, etc). 

1.      Physicians (general, family, pediatrics, etc.)
2.          Nurse Practitioners (NP)
3.        Physician assistants (PA)

•     Private practice

¡  Usually multiple physicians, and not just one person at a clinic (dominant form of primary care.

•     Managed care

¡  HMOs (Health maintenance organizations)

¡  PPOs (preferred provider organizations

•     Hospital clinics and outpatient centers

¡  EX: anticoagulation clinics

¡  Diabetes/ metabolic clinics

¡  Dialysis units

¡  Chemotherapy centers

•      Emergency rooms and “urgent care” centers

¡  Some patients use the ER as their “family physician”. This impact is that they are being charged a LOT more to go to the ER. People without insurance usually do this because they aren’t sick a lot but probably do not know that the costs could be 10x more.

•     Free Clinics
•     Certain governmental facilities

¡  County health Departments

¡  AHECS (Area Health Education Centers)

¡  Indian Health Services (A branch of the Public Health Service)

¡  Veterans Affairs medical Centers

¡  School health clinics

¡  Prison Health Services 

A form of primary care

1. Health promotion (providing resources and get word out about things from flu shots, etc)
2. Disease prevention

Primary prevention (population-based care)

-       Restaurant Inspection

-       Elimination of cancer causing environmental pollutants

-       Smoking bans, etc

Preventive health services (direct patient care)

-       Immunization

-       Screening and early detection, etc. 

**Patient Centered focus for care

**Integrated health care team

**Safety, quality, all play a role in service selection and implementation

**Primary care occurs in the community setting. 

Safe, high quality ambulatory care may require information management and coordination across multiple settings, especially for patients with chronic illnesses. (AHRQ, 2007).  AHECs in the rural US often include a telemedicine component. (contacting a specialist via video technology or something like that so they can see the wound or just for advice that allows for quicker, more affordable patient care.)

AHEC = Area Health Education Center, these centers have telemedicine components. 

1. 1.    Attention to improving health care for Americans living with chronic diseases
2. 2.    Continuing emphasis on medication safety
3. 3.    Greater emphasis on emergency preparedness and bioterrorism

1. Patient Education
2. Pharmacotherapeutic interventions
3. Medication Management
4. Screening and early detection
5. Health promotion and disease prevention

• Identify and prevent drug related problems 
• Establish Treatment goals and outcomes
• Make a pharmacy care plan
  • Initiate
  • Modify
  • Discontinue
  • Monitor Drug therapy

Paid for by Medicare part D

•  A distinct service or group of services that optimize therapeutic outcomes for individual pts
•    Independent of, but can occur in conjunction with, the provision of a medication product
•   Encompasses a broad range of professional activities and responsibilities within the licensed pharmacist’s, or other qualified health care provider’s, scope of practice
  • Includes:  
  •   comprehensive medication review (brown bag)
  • prescriber consultation,
  • patient compliance consultation and education,
  • monitoring

1. Screening and Early detection
2. Health Promotion and Health Disease Prevention

• Approaches to health care that are outside the realm of conventional medicine as practiced in the U.S.
• Complementary = used together with conventional medicine 

• Alternative = used in place of conventional medicine
• Integrative = combines mainstream therapies and CAM therapies for which there is some scientific evidence of safety and efficacy.

1. Decrease in Hospital rates
2. Decrease in Drug Rates
3. Increase in quality of care

•  
  • Increased adherence
  • Increased outcome of treatment
  • Fewer Adverse Drug Events 

l  40 funded projects to provide health care to Delta region counties in MS, among them:

l  Delta Pharmacy Patient Care Management Services

o   To improve medication use and health outcomes in the Medicaid population of targeted areas and evaluate the efficiency of Pharmacy Management Services on medication adherence and disease management

l  Delta Infant Mortality Elimination (DIME)

l  Rural Tele-Emergency/ Tele Stroke:

o   To improve timely treatment of stroke victims. 

• Lack of reimbursement and other incentive
• Pharmacists’ attitudes
• Lack (at times) of a cohesive professional vision and message.
• History of limited support (by schools of pharmacy) for clinical services in community pharmacy settings.
• Lack of “change agents,” leaders who can make the difference
• Public perception

1. Help with patient satisfaction
2. Impact on long term outcomes
3. Quality of Care
4. Disease Management Protocols with Doctors
5. Involvement on multidisciplinary teams
6. Certifications
7. MTMS
8. Mississippi-based Health Initiatives
9. Community pharmacy residency

1. Dynamics in the Health care team
   • Stepping on someones shoes
2. The publics perception of pharmacy
   • Cognitive services not top of mind
3. How will the know of your services?
   • Marketing!
   • Make your scope of practice known to patents

1. ESA [Erythropoietin Stimulating Agent]

2. G- CSF [Granulocyte Colongy Stimulating Factor]

3. GM-CSF [Gronulocyte Macrophage Colony Stimulating Factor] 

4. Small Molecule antagonist of CXCR4

• Trade Name: Epogen or Procrit 
• Type: ESA 
• Function: Stimulates Erythropoeisis (rhEPO)
• Approval Use: Anemia, chronic kidney disease or chronic renal failure, adjunct to chemotherapy, preoperative preparation

Extra Info:

• Trade name:Aranesp
• Type: ESA 
• Function: Stimulates erythropoiesis, longer half life (glycosylated- 2 additional N-linked oligosaccharide chains) 
•  Major Use:Anemia, chronic kidney disease or chronic renal failure, adjunct to chemotherapy, preoperative preparation

Methoxy-PEG-epoetin-beta

(PEG=polyethylene glycol) 

Trade Name: Remicade

Type: Chimeric Mab

Mechanism of Action: TNF-alpha blocker

Indications: Rheumatoid Arthritis; Plaque Psoriasis; Crohn’s Disease; Psoriatic Arthritis; Ankylosing Spondlyitis; UC-Ulcerative colitis

Apporoved: 1998

Other Info: 

• 1st in class Mab for RA
• Given by IV injection